NYTImes running this story today: A Great Day for Nurses!
This article below can be viewed online at: http://www.nytimes.com/library/natio...lif-nurse.html
full text below
California to Set Level of Staffing for Nursing Care
By TODD S. PURDUM
LOS ANGELES -- Over the objections of the state's health care industry, Gov. Gray Davis has signed a bill that will make California the first state to require hospitals to meet fixed nurse-to-patient ratios, in an effort to force higher quality care and combat cost-cutting measures in the place where managed care was born.
Davis signed the new law, backed by the state nurses' union, over the weekend as part of a last batch of bills from this year's legislative session. The session also produced a package of measures that the Democratic Governor signed last month, expanding patients' access to mental health care and their rights to sue their health insurers for punitive damages and seek outside reviews of decisions denying coverage.
Heath care has been a major political issue in California, given the prominence of health maintenance organizations and for-profit hospitals here. And the hospital industry and business groups had lobbied hard against the nurses staffing bill. Davis's Republican predecessor, former Gov. Pete Wilson, vetoed a similar measure two years ago.
At times this year, Davis himself has complained that the Legislature was sending him too many bills on health care, and he has generally taken a cautious approach to this and other issues since his election last year. Even as he signed the nurses staffing bill, he vetoed another measure intended to overhaul the state's nursing home system, saying it was too costly.
The new bill on nurse staffing levels -- which covers all "licensed nurses," including both registered and licensed practical nurses -- does not specify minimum nurse-to-patient ratios, but instead requires the State Department of Health Services to set such standards for general, psychiatric and special hospitals. To secure Davis's support, the measure's sponsor, Assemblywoman Sheila James Kuehl, Democrat of Santa Monica, agreed to sponsor a follow-up bill next year, delaying the implementation by at least a year, until 2002, to allow the state time to work out the desired ratios.
Nurse staffing has been a hot-button issue among health care consumers nationwide in recent years as hospitals have sought to save money by laying off registered nurses and consolidating a range of typical nursing functions in the hands of less-qualified aides. Ms. Kuehl first sponsored the bill at the urging of the nurses' union two years ago, and it passed the Legislature but was vetoed.
"This is one of the most significant days in the history of nursing," Kay McVay, the president of the California Nurses Association, said after Davis signed the bill.
The measure will also bar hospitals from assigning unlicensed workers to perform certain medical procedures, including administering drugs and assessing a patient's condition, and it will prohibit hospitals from shifting nurses trained in one unit to duty in another without adequate preparation.
The state's health care industry had opposed the measure on the grounds that it would impose overly specific requirements on hospitals and increase costs.
"Hospitals are being put under tremendous pressure to lower costs by the managed care companies, which are under pressure from the government and employers, and ultimately, the public," said Walter Zelman, president of the California Association of Health Plans, which represents H.M.O.'s statewide. "If they can avoid it, they would prefer not to have the government mandate a certain rigid standard. Not that the government is always wrong, but rigidity is rigidity. It's easier for the industry to function if it has to meet outcome goals, rather than specific means of achieving them."
But Rose Ann DeMaro, executive director of the California Nurses Association, which represents 200,000 nurses, said the new rules were necessary to address severe gaps in care resulting from cutbacks in nursing staffs and the fact that hospital patients in general are sicker than in the past, because H.M.O.'s resist putting patients in the hospital if they can avoid it, to save money.
A new research report commissioned by the nurses' union, analyzing 18.2 million patient discharge records and other data from 1994 through 1997, found a nearly 9 percent increase in the average number of patients for which each full-time registered nurse was responsible. The ratio rose from one nurse for every 56.87 patients to one for every 62.33. At the same time, patient acuity levels, which measure the severity of illness of patients at the point of discharge from the hospital, increased by more than 3 percent for the categories of "major acuity" and "extreme acuity."
"There has been significant downsizing in the nursing staff of virtually every private hospital in the state," Ms. Kuehl said. "And because of managed care, patients are much more seriously ill before they're even checked in. The dreadful result of the intersection of these two things is that nurses were caring for more and sicker patients."
California regulations require hospitals to assess the illness of patients for every shift, on every floor in every hospital, and then set nurse staffing levels accordingly, Ms. Kuehl said. But she said that made it effectively impossible for the state to enforce any uniform standard.
Allan Zaremberg, president of the California Chamber of Commerce, said it had opposed the bill "because we thought it would add to health care costs and be costly to the overall economy." But he expressed relief that Davis had gone out of his way to find a flexible approach that would not unduly increase costs or require nurses to perform tasks that could be done by others. He also expressed satisfaction that the bill was the only one among those that the chamber had most opposed that Davis had not vetoed.
By contrast, consumer groups and the American Association of Retired Persons expressed dismay that Davis vetoed the nursing home measure, which would have gradually increased the training, number and pay of certified nurse assistants, and doubled fines for violating state nursing home law to a maximum of $50,000 for a patient's death.
In his veto message, Davis said the bill contained "many well-intentioned, commendable features," but placed too great a burden on the state budget, with a five-year cost of more than $500 million. He noted that he had already supported including $72 million in the budget passed this summer to increase the minimum nursing home staff-to-patient ratio and provide a wage increase to patient-care staff.
"Let's let that happen first," said the Governor's press secretary, Michael Bustamante. "Let's let those positions be filled and then let's take a look at what's going on. This bill would have cost taxpayers a half a billion dollars. And the Governor has made clear throughout this entire year that he is hard-pressed to spend money today that we may not have tomorrow."
[This message has been edited by laugh (edited October 16, 1999).]